DSM-V - Major Changes to Addictive Disease Classifications

The first draft of the American Psychiatric Association’s (APA) latest Diagnostic and Statistical Manual of Mental Disorders (DSM-V) eliminates the disease categories for substance abuse and dependence and replaces it with a new “addictions and related disorders” -- just one of several major changes to the “Bible” used almost universally to diagnose (and get insurance reimbursement for) behavioral-health problems.

“Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system,” the APA explained in a Feb. 10 press release.

“The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system,” said Charles O’Brien, M.D., Ph.D., chair of the APA’s DSM Substance-Related Disorders Work Group. “On the other hand, addiction is compulsive drug- seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding.”

The new category for addictive diseases would include a variety of “substance-use disorders” broken down by drug type, such as “cannabis-use disorder” and “alcohol-use disorder.” Diagnostic criteria for these disorders in DSM-V would remain “very similar” to those found in the current DSM-IV, according to APA. However, the symptom of “drug craving” would be added to the criteria, while a symptom that referred to “problems with law enforcement” would be eliminated “because of cultural considerations that make the criteria difficult to apply internationally,” APA said.

Also new to the DSM-V are diagnostic criteria for “cannabis withdrawal,” which the APA says is caused by “cessation of cannabis use that has been heavy and prolonged,” results in “clinically significant distress or impairment in social, occupational, or other important areas of functioning,” and is characterized by at least three of these symptoms: irritability, anger or aggression; nervousness or anxiety; sleep difficulties (insomnia); decreased appetite or weight loss; restlessness; depressed mood; and or physical symptoms such as stomach pain, shakiness or tremors, sweating, fever, chills, and headache.

Battle Over ‘Addiction’ and ‘Dependence’

The APA has gone back and forth between use of the terms “addiction” and “dependence” to describe alcohol and other drug problems, noted researcher Stanton Peele, Ph.D. “Every book I’ve written has the word “addiction” in the title, so I’m glad the term will now be recognized,” wrote Peele in the Huffington Post on Feb. 11. “But the change back may make us wonder whether we will have to reconsider every twenty years or so whether it is more beneficial or harmful to use a word loaded with cultural meanings (“addiction”), or a more neutral term (“dependence”).”

In fact, “dependence” made it into the DSM-IV by just a single vote, O’Brien noted in a May 2006 editorial in the American Journal of Psychiatry co-authored by Nora Volkow, M.D., director of the National Institute on Drug Abuse, and T-K Li, M.D., then-head of the National Institute on Alcohol Abuse and Alcoholism.

“Experience over the past two decades has demonstrated that this decision was a serious mistake,” the trio wrote. “The term ‘dependence’ has traditionally been used to describe ‘physical dependence,’ which refers to the adaptations that result in withdrawal symptoms when drugs, such as alcohol and heroin, are discontinued. Physical dependence is also observed with certain psychoactive medications, such as antidepressants and beta-blockers. However, the adaptations associated with drug withdrawal are distinct from the adaptations that result in addiction, which refers to the loss of control over the intense urges to take the drug even at the expense of adverse consequences.”

Gambling Addiction Makes the Cut

The proposed DSM-V also would add a new category of “behavioral addictions” which contains a single disorder: gambling addiction. “Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with a goal of encouraging additional study,” according to an APA press release.

The net effect is that the term “addiction” would now be officially applied to more than alcohol and other drug related disorders. “There is substantive research that supports the position that pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system,” said O’Brien. “Both are related to poor impulse control and the brain’s system of reward and aggression.”

Peele argues that the APA’s addictions category could be expanded even further to include “life-harming, compulsive” involvement with things like sex and food, which are classified in the DSM-V draft as separate “hypersexuality” and “binge eating” disorders. The APA also is looking to create a classification for patients who suffer withdrawal symptoms when they stop taking tricyclic and selective serotonin reuptake inhibitors, two types of antidepression medication. These “miscellaneous discontinuation syndromes” fall outside the definition of substance-use disorders, APA said, but share some common traits with use of addictive drugs. “If the substance is abruptly discontinued, in some cases the body responds with a rebound effect that creates unpleasant, and sometimes serious, symptoms of withdrawal,” said O’Brien.

Comments Deadline: April 20

APA is accepting public comments on the DSM-V revisions until April 20. “This is the first complete revision of the DSM since 1994,” said Volkow in a Feb. 11 letter to addiction professionals. “... In light of the advances in research on substance abuse and addiction since the last revision, many suggested changes have been proposed in this revision. Therefore, this is an important opportunity to offer your comments on the new criteria.”

All of the proposed changes and information about submitting comments can be found on the DSM5.org, go to the DSM-5 link at the top of the page.

I agree with Wayne Solomon. It is a mistake to remove legal problems as a criteria on the substance abuse scale. When dealing with addicts and the mentally ill, any tool that may assist in getting those in need of care, the care and help they need, is a positive step at progress. Many addicts find themselves in the legal system as a direct result of their illness. It only seems logical that if the cause can be identified here, then it would be a good point for referral in getting those in need of treatment, the treatment they need. The legal system is also a place where many, nearly unreachable addicts and mentally ill that go untreated, such as late stage alcoholics and the homeless, could possibly be reviewed and offered treatment and referrals. Anything that identifies possible mental health patients and puts them in touch with much needed help is a positive. So I feel it is a mistake to take this legal aspect out as a diagnostic criteria on the addiction scale.

23
Thursday, 19 December 2013 10:37

Ken Sanborn LADC

Great! Maybe now we can get rid of the overused, increasingly meaningless, and oft-misunderstood "codependence" term and use the more appropriate "co-addiction" terminology for people addicted to the addicted...maybe we should start referring to them as "meta-addicted"...

22
Saturday, 30 November 2013 12:09

Mary Cooper

I am married to a man that has hypersexuality, sex addiction, cybersex addiction, whatever you want to call it, etc and it has totally destroyed our lives. He had 458 sex buddies on one hookup site, 495 new buddy requests, and had a video of himself posted all over the internet by a blackmailer. He was on too many hookup, pornographic, instant messengers to even count on a daily basis. He has lost his job, became suicidal, my life has been hell, he is now living in a homeless shelter, can't get treatment for this without paying an average of a thousand dollars a day for an in treatment program. I have come to realize that this is a huge societal problem and is destroying many people’s lives. This doesn't just affect the person with the “addiction” but it destroys everything and everyone in its path. Not including it in the DSM-5 is a terrible mistake. Pushing the problem under the rug so to speak does not work! I now have no income, no way to pay bills, my friends and family treat ME differently, and I have been left to pick up the pieces. It is overwhelming to say the least. My husband, our marriage, and my family need help and cannot afford to get it. If pulling out ones hair can be included when it doesn't destroy everything in life around it, it makes no sense to not include sex addiction somewhere. Not enough research on this problem? Start looking to see how many people are in the sex 12 step groups; ask the sex addiction therapists how sex addiction affects society as a whole and look at all the hookup sites and see how many young people are involved. You may be surprised and find your son, daughter, or spouse is available any day, any time for casual sex, one on one sex, and cybersex. I had no idea how rampant this problem is and the affects it is having. Take a look or maybe you already have and thought it is harmless. It is not and needs to be in the DSM-5.

21
Tuesday, 24 September 2013 08:29

Dorian

Addiction is still only called a disease by people in 12-step programs. The DSM still classifies it as a psychiatric "disorder" not a disease.

A disorder is something that causes some form of impairment and subjective distress. A disease is different and the DSM does not use the word "disease."

20
Tuesday, 20 August 2013 20:53

Will Grant

Richard, the person you asked to spell check his entry ("sax and violins")-did you notice his name? Obviously, the writer is either blitzed or missed his nap.

19
Tuesday, 20 August 2013 20:50

Will Grant

Initial practiotionners' assessments compared with the disagreement of subsequentpractioners-all things being equal--could have nothing to do with the addict being more honest initially and less honest as the therapeutic relationship develops (my experience showed the opposite with the addict being less honest at first even though seemingly honest due to meek, timid, beaten behavior). Not one of us is perfect, and with government cutbacks and everyone scrambling for the same dollars, one practictioner is as prone to disagreeing with a prior helper as the second mechanic you take your car to in order to fix the same problem; And as with car trouble discussions, after repairs are paid for and your story is told, experts crawl from the woodwork where none could be found before the huge investment of time and money was made to have the car problem diagnosed initially by ANY professional. "You're at the right place now; we CAN help you." Are professionals beyond such reproach? It only takes a few, correct?

Addiction? Dependence? Isn't the latter more politically correct? If one looks at addiction as a disease such as diabetes and one has to have alcohol at whatever cost (stealing, prostituting. lying), would a diabetic blunt force his grandmother in order to steal from her purse to buy insulin? People "depend" on insulin to function normally; addicts depend on alcohol to function, period. Stop the shakes, make the hurt go away, get the booze, drive without a license, steal the booze. I think from the disease model perspective, a diabetic isn't addicted to insulin, but dependent upon it. An addict isn't "dependent" on heroin but more accurately "reliant" or "contingent" upon it. Moreover, a diabetic makes more sane decisions relative to working and making a living that the really beaten down addict. If you are a "funtioning alcoholic", then perhaps "dependence" fits; however, if you are an addicted alcoholic, you are cycles beyond the "funtional alcoholic".

18
Tuesday, 20 August 2013 20:40

Will Grant

Initial practitioners' assessments compared with the disagreements of subsequent practitioners--all things being equal--could have nothing to do with the addict being more honest initially and less honest as the therapeutic relationship develops (my experience showed the opposite with the addict being less honest at first even though seemingly honest--even convincing himself--due to meek, timid, beaten behavior). Not one of us is perfect, and with government cutbacks and everyone scrambling for the same dollars, one practitioner is as prone to disagreeing with a prior helper as the second mechanic you take your car to in order to fix the same problem might be; and as with car trouble discussions, after repairs are paid for and your story is told, experts crawl from the woodwork of your social circle as know-it-all termites--where none could be found before the huge investment of time and money was made to have the car problem diagnosed initially by ANY professional. "You're at the right place now; we CAN help you." Are professionals beyond such reproach? It only takes a few, correct?

17
Wednesday, 07 August 2013 09:08

Joeg Voll

I think an official text should be written to explain the basics of substance based addiction medicine to non-prof. There's so much false info being used and advocated as fact. I feel this only adds to the stigma surrounding drug addicts. At best it prevents much needed resources from being used effectively. At worst it stops those that need help from getting the treatment needed for this deadly disease. The answer is complicated but I believe educating and understanding is the best place to start.

16
Tuesday, 16 July 2013 21:04

Hello

Michael Allen 8/5/13. I have not seen that long term incarceration stops addictions.

Please learn to spell or spell check your posts prior to posting them, it just makes you look illiterate

13
Wednesday, 08 May 2013 15:52

michael allen

Does incarceration without psycological treatment cure those suffering from 'substance dependence' issues by breaking the cycle of dependence? Does a 'substance dependent disorder' exist without the presence of a substance?

12
Tuesday, 23 April 2013 09:55

Jay

Sorry I missed the deadline. But I want to make a point and hope you will consider it.
Creteria for Substance abuse disorder must be redefined. Patients with severe and persistent mental illness live at the bottom of the sociaty. Some of them do not have a home, relationship and/or job, do not go to school, do not have a car and driver's license. They stay in their apts, smoking dopes or drinking all day long. What kind of "significant imairment or distress" do you expect?

11
Thursday, 11 April 2013 23:03

bados25

In the UK, iatronic benzodiazepine addicyion or tolerence is recognised as a disability and you can get poitical and social support for it. There are no programs or even recognition of this very big global problem in the united states, politically, or by legal aid ,or even by human service agencies. People are dying from this problem at a greater rate than from illegal drugs and there is no legal recognition of it and no official medical stand on it.

10
Thursday, 07 March 2013 07:28

Addiction Hotline

If you were on as many phone calls as I have been on listening to the 1000's of let down middle age men and women, the young teen runaways, and of course you see the celebrities out of control, you would appreciate the attention, any attention that our nations substance abuse problem has risen to. An out of control crisis

9
Saturday, 26 January 2013 20:30

A. CADC

It is real progress to see the DSM V include "cannibas withdrawl". I have observed the exact symptoms listed above. This corrects the commonly held belief that marijuana is not addictive.

8
Wednesday, 23 May 2012 15:25

zorbitor

Anything to help 12 steppers with Master's in Counseling degrees get more insurance money.
http://www2.potsdam.edu/hansondj/Controversies/Is-Alcoholism-a-Disease.html

7
Wednesday, 04 April 2012 11:06

Frederick Cohen, MA, LCADC, CCJP

Over the years, I have seen many clinicians debate over the terms Addiction & Dependence. Even more discrepancies occur in determining the thin line between Abuse and Dependence. Often this diagnostic determination is made by the initial assessment practitioner and subsequently disagreed upon by future practitioners. This could be because patients are not always truthful in the beginning stages of treatment and tend to minimize their addictive activity. As time goes on, and a more enhanced therapeutic relationship is developed, more data is revealed. Using the term Addiction eliminates such discrepancies and clinicians can utilize a severity grading scale. It is my belief the addictions, whether substances, gambling, shopping or sex, share in compulsive methodology and can there be lump together in a generalized manner.

6
Tuesday, 27 March 2012 13:48

David Schnee, LCPC, CRADC

'generalized behavior addiction'???
This is the problem. When applied to everything from Nintendo to Starbucks, the word addiction eventually means nothing and trivializes the seriousness of Substance Dependence.

5
Saturday, 19 June 2010 13:05

RECOVERED ADDICT

The Harsh Reality of Drug Addiction richardmclaughlin007 — January 18, 2009 — after 11 months of sobriety from drug addiction, in 7 short days this man hits the depths of despair and insanity.

http://www.youtube.com/watch?v=OuNWCPDrJsM

This video was shot in Vancouvers downtown eastside by the narrator it is quite extreme, It shows how common place and and readily available drugs are and how people can succomb to a extreme physical reaction from lack of sleep, nutrition and dehydration. This video was made for many different reasons, one being educational the other as mentioned earlier it's common place here in Vancouver, in any other city or town in North America this man would have recieved immediate medical attention but here in Vancouver both the police and ambulance just drive by. If you do not belive me come on down and see our little human circus slash "HARM REDUCTION EXPERIMENT"
This man was spotted two hours later sleeping on a concrete curb as his pillow.
Both the narrator and producer of this video have had spent many years struggling with addiction and have spent hard time in Vancouvers "NOTORIOUS" downtown eastside.
Today they have escaped and are clean and sober and now dedicate there lives to those who still suffer from "THE HARSH REALITY OF ADDICTION"

4
Wednesday, 07 April 2010 13:05

ZVJ

SOUNDS TO ME AS IF YOU ALL HAVE ENTIRELY TOO MUCH FREE TIME! ----MAYBE A NEW CLASSIFICATION IN THE DSM-V SUCH AS SCHIZOTYPAL REVISION D/O WOULD BE APPROPRIATE. .

3
Sunday, 28 March 2010 18:46

Wayne Solomon

The criteria of substance use leading to "problems with law enforcement" should not be eliminated as this is often a most consequential area for individuals with addiction - and very often the criminal justice system facilitates successful referrals to addiction treatment providers. It would be unfortunate for the American Psychiatric Association to eliminate the legal impairment criteria for addiction in America “because of cultural considerations that make the criteria difficult to apply internationally”. I find it hard to believe that legal problems due to alcohol or drug use would be difficult to recognize internationally.

2
Monday, 08 March 2010 11:25

Bentzion Gruber

The reality is that many addictions begin with what Dr. Abraham J. Twersky refers to destructive behaviors (such as needing to know "all" of the latest news, the latest style, gadget, flirting, etc.) which then turns into an addiction when the person has no control over him/herself and their daily life is taken over by their behavior and cannot stop as much as they want to - nothing will stop them.

So it is true with many people nowadays "addicted" to the internet, shopping, spending money, sex, etc. but it all began with a mere behavior weather that person was doing to feel good or to fill up a void does not matter what matters is that perhaps with some psychological, social/emotional help all of it could have been avoided in the first place. Where the focus really needs to be is in detecting such behaviors early on and treating the person - the cause then much cannabis will be saved from the harsh reality of addiction in today’s society where everyone is trying to avoid within him/herself.

Prevention is the key, as the old saying goes "an ounce of prevention is better than a gallon of medicine"

1
Tuesday, 02 March 2010 14:01

Michelle Wilkinson, MA, LPC

This is a fascinating change of events. In the past few years it has been difficult to keep up with what is a socially acceptable term; addiction or dependence. Also, in the past decade an increase in dependence on and access to technology presents a whole new set of challenges. I hope that the 'behavioral addictions' category would strive to include a diagnosis of 'generalized behavior addiction' or 'behavior addiction, not otherwise specified'. This type of diagnosis might help to capture those with compulsive behaviors due to Sex and Love/Relationship issues, and money problems (debting, overspending not related to gambling).